Patient Opt-In

To be completed by any individual who previosly completed the OPT-OUT process and would would now like to OPT-Back-In.

You can allow participating medical groups, hospitals, and other health care-related entities (participants) who care for you and pay for such services to share your health information through SHINE of Missouri, a secure, electronic Health Information Organization (HIE). The purpose of the HIE is to give participants access to your health information for purposes of treatment, payment, and health care operations, as well as other purposes permitted or required by law. Previously, you asked the HIE not to share and use your health information through the HIE. By completing this request, you are directing the HIE to allow your health information to be shared and used through the HIE. Your participation in the HIE is voluntary and your receipt of treatment or health plan coverage for treatment will not be conditioned on whether or not you sign this form.

By signing this Request to Opt-Back-In, you ACKNOWLEDGE, AUTHORIZE and AGREE as follows:

Your health information may be shared with, and used by:

The Participants of the HIE that are involved in your care or payment for your care for purposes of treatment, payment, and health care operations, as well as other purposes permitted or required by law; and,

The participants of other health information organizations with which the HIE connects with for the same purposes.

Your health information that is shared through the HIE may:

Include health information from both before and after today’s date. It may include information related to treatment you received that is possessed by any Participant who is connected to the HIE. A list of Participants, as well as other health information organizations that the HIE connects with can be found at here.

Include, but not be limited to, information about your diagnoses, procedures, allergies, test results (like x-rays or laboratory), and medications that have been prescribed to you. Such information may also include Sensitive Health Information e.g., mental health information, HIV/AIDS, genetic information and test results, some alcohol and drug abuse treatment information, communicable diseases, and developmental disability treatment.

Health care providers who receive health information about you through the HIE may copy and include your health information into their own medical records when caring for you.

It may take between 2 - 5 business days to process your Request to Opt-Back-In and make your information available for sharing through the HIE.

You consent, authorize, and agree that all your health information including, but not limited to, Sensitive Health Information, may be shared with, and used by, all Participants of the HIE as set forth in this Request to Opt-Back-In.

*SHINE of Missouri is the Health Information Exchange endorsed by the MIssouri State Medical Association and operated by KaMMCO Health Solutions, Inc.

ALL FORMS FIELDS BELOW ARE REQUIRED UNLESS NOTED "OPTIONAL."

First Name:

Middle Name:

Last Name:

DOB:

Gender:

Address:

City:

State:

Zip:

Phone Number:

Social Security Number (Optional):

Patient Email (Optional):

Physician/Facility Name (Optional):

Physician office/Facility email (Optional):

I am completing this form as a legal representative of the above noted patient.